AETNA HEALTH FUND BENEFITS AT-A-GLANCE |
| |
In-Network |
Out-of-Network |
| TYPE OF CARE |
The Aetna Health Fund is a point of service (POS) plan, which means that at the time of service, you have the choice of using an in-network or out-of-network provider. Benefits are higher if you use in-network providers. |
ANNUAL HRA ALLOCATION
(if you use in-network providers, Aetna will deduct the eligible expense amount directly from your HRA; if you use an
out-of-network provider, you will need to file a claim)
|
| Employee Only: |
$750 |
| Employee+Spouse/Domestic Partner: |
$1,000 |
| Employee+Child(ren): |
$1,000 |
| Employee+ Spouse/ Domestic Partner+Child: |
$1,250 |
|
CALENDAR YEAR DEDUCTIBLE
(does not apply to preventive care services and prescription drug expenses that Aetna identifies as Chronic or Preventive)
|
| Employee Only: |
|
$1,250 |
|
Employee Only: |
|
$2,000 |
Employee+Spouse/
Domestic Partner: |
|
$2,000 |
|
Employee+Spouse/
Domestic Partner:
|
|
$4,000 |
| Employee+Child(ren): |
|
$2,000 |
|
Employee+Child(ren): |
|
$4,000 |
Employee+Spouse/
Domestic Partner+Child:
|
|
$2,250 |
|
Employee+Spouse/
Domestic Partner+Child:
|
|
$4,250 |
Your HRA payments that Sun funds also apply to your deductible. |
|
| HEALTH PLAN COVERAGE |
Out-of-Pocket Maximum*
(this is the most you would have to pay in a calendar year before the plan pays at 100%)
|
| Office Visit |
| Preventive Care |
| Inpatient Hospital Services |
| Prescription Drugs |
|
| Note: The benefit amounts below for eligible medical and prescription drug expenses do not apply until you have used up the money in your HRA and have met your calendar year deductible (except for preventive care services and prescription drug expenses that Aetna identifies as Chronic or Preventive). |
| Employee Only: |
|
$1,500* |
|
Employee Only: |
|
$6,000* |
Employee+Spouse/
Domestic Partner: |
|
$3,000* |
|
Employee+Spouse/
Domestic Partner:
|
|
$12,000* |
| Employee+Child(ren): |
|
$3,000* |
|
Employee+Child(ren): |
|
$12,000* |
Employee+Spouse/
Domestic Partner+Child:
|
|
$5,000* |
|
Employee+Spouse/
Domestic Partner+Child:
|
|
$18,000* |
| *PLUS DEDUCTIBLE |
|
*PLUS DEDUCTIBLE |
|
|
| 90% of negotiated charges |
|
70% of reasonable and customary charges |
|
100% of negotiated charges
DEDUCTIBLE WAIVED |
|
70% of reasonable and customary charges
DEDUCTIBLE WAIVED |
|
| 90% of negotiated charges |
|
70% of reasonable and customary charges |
|
| 100% after you pay the applicable coinsurance for generic, brand name formulary, and brand name non formulary drugs. |
|
| *Your overall financial responsibility may be less than the above out-of-pocket maximums: HRA payments reduce your calendar year deductible and the amount of expenses that you pay to meet the balance of your deductible will reduce your out-of-pocket maximum. |
|
